Health inspection·May 12, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. 3. On 5/9/23 at 12:18 pm, R13 stated They keep on sending me to the hospital. I was sick. I can't remember what was going on but I am better now. Residents Affected - Some The Progress Note for R13, dated 2/18/23 through 2/19/23 document R13 was sent to the local hospital for an evaluation and was admitted to the hospital for Altered Mental Status. The Progress Note for R13, dated 3/18/23 documents R13 was transferred to the local hospital for an evaluation and was admitted to the hospital for Hypercapnia. There is no documentation regarding the written notification of R13's transfers to the local hospital being provided to R13 or R13's Responsible Party for R13's 2/18/23 and 3/18/23 hospital transfers. On 5/10/23 at 12:20 pm, V2 DON/Director of Nursing confirmed there was no written notification of transfer given to R13 or to R13's representative. On 5/10/23 at 12:30 pm, V7 SSD/Social Service Director confirmed there were no discharge notifications made to the facility's Ombudsman for R10, R13, or R59 for their discharges to the local hospital because the report system did not pull those residents names and therefore they did not generate onto the report. 4. Upon entrance to the facility on 5/9/23, R16 was not observed or able to be located in the facility. On 5/09/23 at 11:12 AM V1 (Administrator) stated, The original census number we gave you is incorrect. (R16) transferred out last night, after midnight. R16's Census Report documents that R16 was transferred out to the hospital on 5/9/23 at 12:46 AM. R16's Transfer to Hospital Summary on 5/9/23 at 12:51 AM, documents that V20 (R16's Physician) was notified of R16's complaints of severe abdominal pain, abdominal distention and hypoactive bowel sounds. V20 ordered to send R16 to the local area emergency room for evaluation and treatment. Around 12:35 AM, R16 was transported via ambulance to the local area hospital. R16's Nursing Note on 5/10/23 at 6:38 PM documents R16 was hospitalized related to a Bowel Obstruction. As of 5/12/23, R16's medical record did not document that a written reason for R16's transfer was provided to R16 or R16's Representative for R16's 5/9/23 transfer to the local area hospital. On 5/10/23 at 12:12 PM, V2 (Director of Nursing) stated that written reasons for a resident's transfer out of the facility are not provided to the resident or the resident's representative. V2 stated, We just call. Based on observation, interview and record review the facility failed to provide a written reason for Transfer/Discharge for four Residents (R10, R13, R16 and R59) and failed to notify the local (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ombudsman of a Resident discharge for three Residents (R10, R13 and R59) of 18 reviewed for hospitalization and discharge in a sample of 30. Findings include: Facility Notice of Transfer and Discharge Policy, revised 10/24/22, documents: Notify the resident and the Resident's Representative of the Transfer or Discharge and the reasons for the move in writing in a language and manner they understand. The facility will send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. This may be done by submitting a monthly list of discharges to the Ombudsman. The facility's monthly admission and Discharge Reports emailed to the local Ombudsman, dated February through April 2023 do not include R10, R13, or R59's discharges to the local hospital. 1. R10's Face Sheet, dated 5/12/23, documents that V13 (R10's Power of Attorney/POA) is R10's Emergency Contact/Health Care Power of Attorney. R10's Nursing Note, dated 4/13/23 at 6:12 pm and 7:11 pm, documents that R10 was sent to the local Emergency Department for evaluation of not feeling right and feeling the same way as last time when R10 had a stroke. R10's Nursing Notes, dated 4/13/23 through 4/14/23, does not document that a written notification was provided to R10 or V13. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R10 or V13 (R10's Responsible Party). 2. R59's Face Sheet, dated 5/12/23, documents that V14 (R10's Power of Attorney/POA) is R59's Emergency Contact/Health Care Power of Attorney. R59's Nursing Note, dated 2/6/2 at 11:26 pm and 11:31 pm, documents that R59 was sent to the local Emergency Department for evaluation via Local Emergency System Ambulance for a change in condition. R59's Nursing Notes, dated 2/5/23 through 2/6/23, does not document that a written notification was provided to R59 or V14. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R59 or V14 (Responsible Party). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. 3. On 5/9/23 at 12:18 pm, R13 stated she has been to the hospital a few times this year and was not given any information regarding the facility's bed-hold policy when she went to the hospital. Residents Affected - Some The Progress Note for R13, dated 2/18/23, documents R13 was sent to the local hospital and was admitted for change in mental status. There is no documentation regarding the facility bed-hold policy being given to R13 or R13's Representative at the time of R13's transfer. On 5/10/23 at 12:20 pm, V2 DON/Director to Nursing confirmed R13 was sent to the local hospital and does not know if the bed-hold policy was given to R13 or R13's representative and there is no documentation that it was provided. 4. Upon entrance to the facility on 5/9/23, R16 was not observed or able to be located in the facility. On 5/09/23 at 11:12 AM V1 (Administrator) stated, The original census number we gave you is incorrect. (R16) transferred out last night, after midnight. R16's Census Report documents that R16 was transferred out to the hospital on 5/9/23 at 12:46 AM. R16's Transfer to Hospital Summary on 5/9/23 at 12:51 AM, documents that V20 (R16's Physician) was notified of R16's complaints of severe abdominal pain, abdominal distention and hypoactive bowel sounds. V20 ordered to send R16 to the local area emergency room for evaluation and treatment. Around 12:35 AM, R16 was transported via ambulance to the local area hospital. R16's Nursing Note on 5/10/23 at 6:38 PM documents R16 was hospitalized related to a Bowel Obstruction. As of 5/12/23, R16's medical record did not document that the facility's Bed Hold Policy was provided to R16 or R16's Representative. On 5/10/23 at 12:12 PM, V2 stated that Bed Hold Policies are given to the Resident/Resident's Representative upon each transfer out of the facility by the nurses. V2 stated that there should be some type of documentation in the resident's medical record documenting that the Bed Hold Policy was provided. At this time, V2 verified that R16's medical record did not document that a Bed Hold Policy was provided to R16 or R16's Representative for R16's 5/9/23 transfer to the local area hospital and should. Based on observation, interview and record review the facility failed to provide the resident and/or the resident representative with the facility bed-hold policy upon hospital transfer for four (R10, R13, R16 and R59) of 18 residents reviewed for Transfer/Discharge in a sample of 30. Findings include: The Facility Bed Hold and Return to Facility Policy and Procedure, revised 9-16-17, documents: To ensure that residents and/or resident representatives are notified of the facility bed-hold policy and conditions for return to facility upon admission and at the time of a transfer from the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1. R10's Face Sheet, dated 5/12/23, documents that V13 (R10's Power of Attorney/POA) is R10's Emergency Contact/Health Care Power of Attorney. R10's Nursing Note, dated 4/13/23 at 6:12 pm and 7:11 pm, documents that R10 was sent to the local Emergency Department for evaluation of not feeling right and feeling the same way as last time when R10 had a stroke. R10's Nursing Notes, dated 4/13/23 through 4/14/23, does not document that notification, in writing, was provided to R10 or V13. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R10 or V13 (R10's Responsible Party). 2. R59's Face Sheet, dated 5/12/23, documents that V14 (R10's Power of Attorney/POA) is R59's Emergency Contact/Health Care Power of Attorney. R59's Nursing Note, dated 2/6/2 at 11:26 pm and 11:31 pm, documents that R59 was sent to the local Emergency Department for evaluation via Local Emergency System Ambulance for a change in condition. R59's Nursing Notes, dated 2/5/23 through 2/6/23, does not document that notification, in writing, was provided to R59 or V14. On 05/10/23 at 12:14 pm, V2 (Director of Nursing) stated, I do not see that any written notification or Bed Hold Policy was given to R59 or V14 (Responsible Party). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to immediately report and investigate a fall for one of three residents (R35) reviewed for accidents and supervision in the sample of 30. Residents Affected - Few Findings include: The facility's Incident and Accidents policy, reviewed 4/7/2019, states, Policy: The Incident/Accident Report is completed for all unexplained bruises or abrasions, all accidents or incidents where there is injury or the potential to result in injury, allegations of theft and abuse registered by residents, visitors or other, and resident-to-resident altercations. Procedure: An 'incident' is defined as any happening, not consistent with the routine operation of the facility, that does not result in bodily or property. An 'accident' is defined as any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident/accident report will be completed for: 1. All serious accidents or incidents of residents. 2. All injuries of staff, families, and visitors. 3. All unusual occurrences. 6. All unexpected events that occur that cause actual or potential harm to a resident or employee. 1. An incident/accident report is to be completed by a RN (Registered Nurse) or LPN (Licensed Practical Nurse), and is to include: a. Date and time of an incident/accident. b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. 4. Documentation in nurses' notes is to include: a. A description of the occurrence, the extent of the injury (if any), the assessment of the resident, vital signs, treatment rendered, and parties notified. The facility's Fall Prevention Program, revised 11/21/17, states, Accident/Incident Reports involving falls will be reviewed by the Interdisciplinary Team to ensure appropriate care and services were provided and determine possible safety interventions. R35's Facesheet documents R35 admitted to the facility with diagnoses to include but not limited to: Morbid (Severe) Obesity; Abnormal Posture; Other Lack of Coordination; Other Low Back Pain; Muscle Spasm of Back; Difficulty in Walking; Shortness of Breath and Dependence on Supplemental Oxygen. R35's Fall Risk Assessment, dated 4/9/23 documents R35 is at risk for falls. R35's Interdisciplinary Team/IDT Note on 5/4/2023 at 8:37 AM documents a late entry note stating that R35 became weak and was assisted to the floor while transferring. R35's Current Care Plan documents R35 is at risk for falls and documents that R35 was lowered to the floor when transferring. R35's Census List documents that R35 was transferred to the local area hospital on 4/11/23. No further transfers to the hospital are documented for April or May 2023. R35's Witnessed Fall Report, dated 5/3/23 and completed by V2 (Director of Nursing), states, (Local State Agency Surveyor) had notified this writer (V2) that (R35) stated she had fallen the day she was sent to ER (Emergency Room) (4/11/23). Immediate Action Taken: Investigation was initiated on (R35) stating she fell. No injuries were noted. (R35) became weak and O2 (Oxygen) was 86% (percent). (R35) was COVID positive at time. (R35) was sent to ER due to having low sat (oxygen saturation), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few increased RR (Respiratory Rate) and SOB (Shortness of Breath). I notified POA (Power of Attorney) and MD (Medical Doctor). Predisposing Situation Factors are documented as during transfer. Witnesses are documented as V8 (Registered Nurse/RN), V5 (Wound Nurse/Licensed Practical Nurse), and V10 (Certified Nursing Assistant). V8's witness statements states, (RN) stated she was called into the room because (R35) was weak. When transferring (R35), she was lowered to the floor. Sent on stretcher to ER. V5's witness statements states, (R35) had been lowered to the floor due to being weak and I was assisting staff with (mechanical lift) to get her off the floor. V10's witness statements states, We were transferring (R35). She became weak and stated she was going to fall. She was sitting half on the bed and said she couldn't stand. We lowered her (R35) to the floor. R35's Nursing Note on 4/11/2023 at 1:12 PM states, At 12:00 PM, Staff called the writer (V8) while doing medication pass to help resident to get on her chair. Upon entering the room, (R35) appears to be pale, weak and has increase RR (respiratory rate) and has difficulty of breathing. Tried to position (R35) on comfortable position. VS/Vital Signs taken : 110/73 RR: 30, temp; 97.0, O2 (Oxygen) sat/saturation : 86. Put on oxygen via mask but resident took out, refusing mask to put on despite explaining the benefits of having the mask. Resident Oxygen goes below 86% on 3lpm (three liters per minute). Increased to 4 lpm to keep the oxygen @ (at) 90% but oxygen is going down. Notified MD @ 12:14 and ordered to send to hospital. As of 5/12/23, this same Nursing Note did not contain any documentation that R35 had to be lowered to the floor by staff during a transfer. On 5/12/23 at 9:14 AM, V9 (Certified Nursing Assistant/CNA) stated that on 4/11/23, R35 was sitting on the side of the bed holding onto R35's walker, trying to stand up. V9 stated that V9 was called into the room by V10 (CNA) because R35 kept trying to get up without help. V9 stated that R35's bottom began sliding off the side of the bed, so R35 was then lowered to the ground by staff. V9 stated the mechanical lift was used to get R35 off the floor and back into bed and that R35 transferred to the hospital soon after. V9 stated, Since (R35) ended up on the floor, I would definitely report that to my nurse. V9 stated that R35's nurse (V8) was present in the room during V8's fall. V9 denied that a witness statement was obtained from V9 regarding R35's fall. On 5/12/23 at 10:11 AM, V10 (CNA) stated that around lunch time on 4/11/23, R35 had been sick and was sitting up on the side of R35's bed. V10 stated that R35 seemed confused and kept trying to transfer to R35's wheelchair without assistance. V10 stated that V10 yelled for help and V8 and V9 came into R35's room to assist. V10 stated that R35 said she could not stand and was going to fall. V10 stated that the staff members could not get R35's bottom on the bed enough, so R35 was instead, lowered to the floor. V10 stated a mechanical lift was used to get R35 off the floor and into R35's bed. V10 stated this fall occurred the same day that R35 was sent to the hospital for COVID. V10 stated, It is still considered a fall even if it is planned. V10 denied that a witness statement was obtained from V10 regarding R35's fall before 5/3/23. On 5/10/23 at 11:10 AM, V5 (Wound Nurse/Licensed Practical Nurse) stated that in mid April, R35 was diagnosed with COVID and had to be hospitalized . V5 stated that V5 walked into R35's room when the staff was using the mechanical lift to get R35 off of the floor. V5 stated that V10 (Certified Nursing Assistant) was in the room and reported to V5 that R35 had been lowered to the floor by staff. V5 stated R35's fall should have been reported and is unsure if it was. V5 denied reporting R35's fall to V2 (Director of Nursing). On 5/10/23 at 12:12 PM, V2 (Director of Nursing) stated that last week a surveyor with the local state agency had notified V2 that R35 had communicated that on the day R35 transferred to the local area hospital (4/11/23), R35 had fallen to floor with staff. V2 stated that a fall investigation was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few opened up on 5/3/23, the day V2 became aware that a fall had occurred with R35. V2 stated that V2 investigates falls in the facility and V2 would expect to be notified about R35's fall and that V2 was not. V2 stated that V2 did not know R35 had to be lowered to the ground by staff until it was reported by the surveyor. V2 stated that even though R35 was lowered to the ground by staff and R35 was not injured, the incident still requires immediate reporting by staff. V2 stated V8 should have created an incident report on 4/11/23 when R35 fell, but V8 did not. V2 stated all staff was in-serviced on reporting of falls and resident transfers. V2 denied that R35 has had any falls since returning back from the hospital. On 5/10/23 and 5/12/23, attempts were made to speak with V8. Phone calls were not returned and V8 was not observed in the facility. As of 5/12/23, R35's medical record did not contain any documentation that R35's 4/11/23 fall was reported or investigated prior to 5/3/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to follow interventions to decrease anxiety and re-traumatization, failed to identify triggers related to history of trauma/abuse and failed to develop a comprehensive care plan to provide Trauma Informed Care for two residents (R11, R47) of five residents reviewed for Trauma Infromed Care in the sample of 30. Residents Affected - Few Findings include: Facility Policy/Behavioral Health Services (Program) dated 10/24/22 documents: The facility will attempt to identify, to the extent possible, any previous history of mental illness, trauma, abuse, substance use, comorbidities, pattern of behaviors, preferences, interests, daily routines, medication use and effective behavior management interventions in developing an individualized plan of care. The care plan should include a well-defined problem-statement and should outline the goals of care. It should include measurable objectives and timetables for individualized interventions. The care plan should reflect: Identified or suspected triggers specific to each resident that may initiate or exacerbate behavioral symptoms. Specific individualized interventions for responding to target behaviors/triggers and expressions of distress. Individualized, person-centered approaches should be implemented to address expressions of distress. On 5/12/23 at 12:30pm V1, Administrator stated that the facility does not currently have a specific policy addressing PTSD (Post Traumatic Stress Disorder) or Trauma Informed Care. 1. Current POS (Physician Order Sheet) indicates R47 has diagnoses that include Alzheimer's Disease with Late Onset, Major Depressive Disorder and Generalized Anxiety Disorder. Current Care Plan indicates R47 has a history of trauma related to sexual and physical abuse - date initiated 5/5/20. Care plan does not list specific, individualized triggers to decrease potential for re-traumatization. Care Plan indicates R47 is non-compliant/resistive to care with showers, baths and frequently refuses to change soiled briefs and bedding. Interventions for this problem include: -have staff that is most compatible provide care and (dated 5/11/21); -leave (R47) alone and re-approach later as needed (dated 5/11/21); -if response is aggressive, staff to walk away calmly and approach later (dated 2/21/19); (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -if (R47) resists with ADL's (Activities of Daily Living) reassure, leave and return 5-10 minutes later and try again (dated 5/6/21); -provide care with teams of 2 staff members (dated 6/10/19); -keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (dated 11/6/20). Social Service LookBack Summary dated 5/2/23 at 1:10pm indicates R47 has a history of physical/emotional trauma and sexual violence. Summary indicates R47 experienced sexual abuse at the age of 4 and was abused by her husband when he was drinking. Incident Investigation dated 4/25/23 indicates R47 initially stated that she was roughed up by V15, Agency CNA (Certified Nurse Assistant) on that date at 5:30am. Incident report indicates R47 was incontinent of a large amount of stool and required incontinent care as stool was not only spilling out of R47's brief, but had also soiled her gown and bedding. Report indicates R47 told V15 it was not time to be cleaned up because it was not 2pm and she only gets cleaned up at 2pm. V15's witness statement dated 4/23/23 indicates R47 verbally resisted care, but was not physically aggressive. V15 indicated she only wanted to get R47 cleaned from the bowel movement. Witness statement dated 4/25/23 from V17, LPN (Licensed Practical Nurse) indicates she told R47 that they couldn't leave her with feces all over. Statement indicates V15 washed the feces off of R47 while R47 cursed at V15. Statement indicates V17 thought R47 had these behaviors because she yells, screams and calls people names when cares are performed. On 5/10/23 at 10:30am R47 was seen in bed and remembered meeting briefly on 5/9/23. R47 denied being hit or abused by V15 (on 4/23/23) but did state that she has the right to refuse care. R47 stated that she just woke up (on 4/23/23) and doesn't like to be woke up because she can't go back to sleep. R47 stated she wasn't even fully awake when V15 told her she had to get cleaned up. R47 stated that V15 proceeded to change her clothes and bedding even though she told V15 not to do it. On 5/11/23 at 11:50am V19, CNA stated that she frequently provides care to R47, but it took about 6 months for R47 to be really comfortable with V19. V19 stated that at first she assisted another CNA when providing care to R47 until R47 became comfortable allowing V19 to provide care But it took a long time. V19 stated R47 can be verbally rude if she doesn't like them. V19 stated she followed V15 on 4/23/23 when R47 was upset with V15. V19 stated that V15 is a very sweet and caring CNA and would never abuse a resident but V15 should have just left the room - even though R47 had feces all over - and told someone else to clean up R47. V19 stated that it's better to back away and re-approach (R47) does calm down after awhile. V19 stated she was unaware of R47's history of trauma But now it makes sense that she acts the way she does when she needs to have personal care. On 5/11/23 at 1:30pm V7, SSD (Social Service Director) stated that he recently asked R47 more specific questions regarding her history of trauma and abuse and was told she was sexually abused at four years of age and physically abused by her spouse when he was drinking. V7 stated if R47 told staff No they should've left, notified the nurse and either re-approached or got someone else to provide the care. V7 stated that really goes for any resident but especially a resident with a history of trauma/abuse. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. The Diagnosis Report for R11 documents the following diagnoses for R11 as: Schizoaffective Disorder, Paranoid Schizophrenia, Bipolar disorder, Major Depressive Disorder, and unspecified Psychosis. The SS (Social Service) - Lookback Summary for R11, dated 6/15/21, documents R11 was assessed for Trauma Informed Care on 6/15/21 with documentation Resident will not talk about her past. Per history on previous assessments, resident has experienced physical/emotional trauma. Behavioral health diagnoses are listed as Paranoid Schizophrenia and Schizoaffective Disorder. Triggers that alarm or distress as indicated by individual or loved one/responsible party include: loud noises, change in routine or living arrangement, and crowded/confined spaces. The Care Plan section, numbered 2 on this assessment form documents Trauma informed care planning was not completed. R11's current Care Plan does not include or mention Trauma Informed Care Plan or triggers to trauma. On 5/9/23 1:57 pm, R11 was in her room, the lights were out and curtains pulled at the window. R11 was lying in bed with blankets pulled up around her neck. During conversation R11 was raising voice and frowning. R11 stated she does not like to use the community shower room because she is fearful of rape and stated she does not like to socialize with a lot of people and prefers to be by herself. On 5/10/23 at 8:30 am, R11 came out of her darkened room with head down and was walking toward the dining room. On 5/10/23 at 2:43 pm, R11 was in her room, the lights were not on and room dark with curtain pulled at the window. R11 was coming out of her bathroom and stated someone is always telling her what to do and when to do it. R11 pulled bedding back and laid down in bed and pulled her blankets up to her neck. On 5/12/23 at 9:25 am, V7 SSD (Social Service Director) stated he started working at the facility about a year ago and has not been able to get all the trauma informed care assessments completed yet for all the residents and has a plan in place to do them when their quarterly assessments come due. V7 SSD stated the assessments are to be done upon admission, quarterly and annually. V7 SSD confirmed the last Trauma Informed Care assessment was last completed for R11 on 6/15/21 and the care plan was not developed. V7 SSD stated he is going to complete R11's assessment with her next quarterly assessment period. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide indication for use of an antipsychotic medication and failed to identify specific target behaviors for two residents (R24, R25) who receive antipsychotic medications with diagnosis of Dementia of three reviewed for unnecessary psychotropic medications in the sample of 30. Findings include: Facility Policy/Psychotropic Medication - Gradual Dose Reduction dated/revised 2/1/18 documents: Informed consent shall be obtained as follows: Psychotropic medication shall not be administered without the informed consent of the resident or the authorized resident representative. Facility Policy/Behavioral Health Services (program) dated/revised 10/24/22 documents: The care plan should reflect: For psychotropic medications include indication/rationale for use, specific target behaviors, monitoring for efficacy and/or adverse consequences and (when applicable) plans for gradual dose reduction (GDR) if an antipsychotic medication is used. 1. Consent For Psychotropic Medications indicates R24 signed a consent on 12/23/21 to receive Seroquel (antipsychotic) 50mg (milligrams) three times per day for Vascular Dementia with Behaviors and on 3/30/23 to receive Seroquel 50mg at bedtime for Bipolar Disorder. Psychotropic consents do not identify target behaviors or specific indication for use for administration of Seroquel. Current POS (Physician Order Summary) indicates R24 receives Seroquel 50mg at bedtime (initiated 3/30/23) for Bipolar Disorder, Current Episode Manic Severe with Psychotic Features. On 5/10/23 at 11:57am R24 was pleasant, social and appropriate with conversation. R24 stated he takes Seroquel to Relax. Current Care Plan (dated Initiated 12/24/21) indicates R24 uses psychotropic medications related to behavior management, disease process (Bipolar Disorder, Dementia, Major Depressive Disorder, Insomnia, Pain) Potential for injury to self or others. Interventions: Monitor/record occurrence of/for target behavior symptoms (pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, etc.) On 5/12/23 at 11:40am V3, Psychotropic Nurse stated that the behaviors to monitor in R24's care plan populate and are not specific to R24. V3 stated that she is only aware of anxiety and a history of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145413 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Goldwater Care Toluca 101 East via Ghiglieri Toluca, IL 61369 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 suicidal ideation for R24. Level of Harm - Minimal harm or potential for actual harm Behavior monitoring (April and May 2023) indicates R24 had one episode of abusive language. Residents Affected - Few Current Comprehensive Assessment indicates R24 has no psychosis and no behaviors identified on assessments dated 12/12/23 and 3/13/23. On 5/11/23 at 3:30pm V7, SSD (Social Service Director) stated R24 receives Seroquel for anxiety. V7 was not aware of any other behaviors displayed by R24. V7 acknowledged antipsychotics are not generally prescribed just for anxiety. 2) Current POS indicates R25 is [AGE] years old and has diagnoses that include Unspecified Dementia, Mild without Behavioral, Psychotic, Mood Disturbance and Anxiety. POS indicates R25 has orders for Risperdal (0.5mg) daily for Schizoaffective Disorder. R25 was seen in her room/milieu at various times of the day on 5/9/23, 5/10/23 and 5/11/23. R25 did not display any observable behaviors, was cooperative and appropriate. Consent for Psychotropic Medications dated 9/23/21 indicates consent was received for Risperdal 0.5mg twice daily for psychosis. Consent does not indicate target behaviors, specific psychotic behaviors or specific indication for use. Current Care Plan (date initiated 11/10/20) indicates R25 has a history of being non-compliant/resistive related to history of rejecting care, dementia with behavioral disturbance. Care Plan indicates R25 has a history of accusing her family of trying to hurt her. Care Plan indicates R25 has delusions related to her daughter trying to kill her and has made false accusations toward staff. Care Plan indicates R25 uses psychotropic medication related to behavior management and pain management. Care plan does not specifically identify antipsychotic medication or specific target behaviors. Behavior monitoring (April and May 2023) indicates R25 had one incident of abusive language. On 5/11/23 at 3:30pm V7, SSD (Social Service Director) stated R25 receives Risperdal for a history of hallucinations and delusions. V7 was not aware of any other behaviors or recent hallucinations and/or delusions displayed by R25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145413 If continuation sheet Page 13 of 13